Manual Therapy 15 (2010) 286291

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Manual Therapy
journal homepage: www.elsevier.com/math

Professional issue

What is manipulation? A reappraisal

David W. Evans a, *, Nicholas Lucas b
a b

Research Centre, British School of Osteopathy, London SE1 1JE, UK Sydney School of Public Health, University of Sydney, Australia

a r t i c l e i n f o
Article history: Received 27 November 2008 Received in revised form 3 November 2009 Accepted 21 December 2009 Keywords: Joint manipulation Spinal manipulation Taxonomy Denition

a b s t r a c t
Due primarily to its colloquial function, manipulation is a poor term for distinguishing one healthcare intervention from another. With reports continuing to associate serious adverse events with manipulation, particularly relating to its use in the cervical spine, it is essential that the term be used appropriately and in accordance with a valid denition. The purpose of this paper is to identify empirically-derived features that we propose to be necessary and collectively sufcient for the formation of a valid denition for manipulation. A nal denition is not offered. However, arguments for and against the inclusion of features are presented. Importantly, these features are explicitly divided into two categories: the action (that which the practitioner does to the recipient) and the mechanical response (that which occurs within the recipient). The proposed features are: 1) A force is applied to the recipient; 2) The line of action of this force is perpendicular to the articular surface of the affected joint; 3) The applied force creates motion at a joint; 4) This joint motion includes articular surface separation; 5) Cavitation occurs within the affected joint. Crown Copyright 2009 Published by Elsevier Ltd. All rights reserved.

1. Introduction Scientic enquiry often requires researchers to consider the foundations upon which important clinical and academic assumptions have been built. For the professions that use manual therapy, few foundations lie as deep as denitions of the very interventions that distinguish manual therapy from other areas of healthcare. It is difcult for practitioners to make rational decisions about the use of an intervention when that intervention is poorly dened or not mechanistically understood. Indeed, the ramications of this uncertainty may be more far reaching than judgements made by individual clinicians. For example, denitions of healthcare interventions may be used by purchasers to make inferences about the potential efcacy, safety and appropriateness of that intervention, when applied to populations (e.g. Shekelle et al., 1991; Coulter et al., 1996; Gatterman et al., 2001). Given that clinical trials have so far provided few clear answers to inform the choice of one physical treatment over another, particularly in relation to musculoskeletal problems (Keller et al., 2007; van der Velde et al., 2008), the perceived characteristics of an intervention are likely to be used to provide clinical guidance. In addition, with reports continuing to associate serious adverse events with manipulation (e.g. Ernst, 2007), particularly

relating to its use in the cervical spine, the term should be used appropriately and in accordance with a valid denition. Manipulation is one intervention for which a satisfactory denition is lacking. Due primarily to its colloquial function, manipulation is a poor term for distinguishing one physical treatment from another. Indeed, so vague is the term that when used in scientic journals, supplementary details are often required to differentiate real manipulation from its manual therapy counterparts (e.g. Keller et al., 2002; Harvey et al., 2003; Skyba et al., 2003; Colloca et al., 2004, 2006; Song et al., 2006). Oversights of this kind may be avoided if what is currently termed manipulation were accurately dened. The purpose of this paper is to present features proposed to be necessary components of a valid denition of manipulation. A nal denition of manipulation is not offered, but arguments for and against the inclusion of these empirically-derived features are presented as a rst step in this direction. 2. Dening manipulation Prior to contemplating a denition of manipulation, it is necessary to consider how a denition should be formed. Established criteria for a denition are presented in Table 1 and are compared to those criteria that meet the requirements for a description. A useful denition of manipulation should encompass all characteristics that empirical research has shown to be universally valid in all parts of the body, yet exclude any

* Corresponding author. Tel.: 44 7853914487. E-mail address: dwe@spinalmanipulation.org.uk (D.W. Evans).

1356-689X/$ see front matter Crown Copyright 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2009.12.009

D.W. Evans, N. Lucas / Manual Therapy 15 (2010) 286291 Table 1 A comparison of the criteria required for denitions and descriptions. Denition A statement expressing the essential nature of something May be stipulated, or assigned meaning When applied to a class of phenomena, must apply fully to all members of the class From OConnor et al., 1997. Description Discourse intended to give a mental image of something experimental Must derive from observation or experience When applied to a class of phenomena, may yield an aggregate set of features, all of which need to apply to each particular member of the class

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et al., 2006; Bolton and Budgell, 2006; Williams et al., 2007). However, rather than including these secondary responses, which have yet to be clearly delineated, we shall follow the convention of prior denitions and limit our discussion to the action of the practitioner and the passive mechanical response within the recipient. 3. Features of manipulation Several empirically-derived features are likely to be necessary to dene manipulation. A necessary feature should be applicable irrespective of the body region in which manipulation is achieved. We consider that, although each feature may not be unique to manipulation, their combination will be. It is this combination that will represent a framework to sufciently dene manipulation. We have divided these features into two categories: (1) the action (that which the practitioner does to the recipient), and (2) the accompanying mechanical response (that which occurs within the recipient). The merits of each identied feature are discussed below. 3.1. Action (that which the practitioner does to the patient) 3.1.1. A force is applied to the recipient Manipulation involves a force being applied to the recipient. Most commonly, this force is externally generated and is usually applied to the recipient by physical contact at the skin surface (Kawchuk et al., 1992; Herzog et al., 1993a, 2001; van Zoest and Gosselin, 2003). The force may include reaction forces from furniture, such as a plinth or chair (Kirstukas and Backman, 1999) and, in some circumstances, gravitational force may be utilised. The application of force is proposed to be a necessary feature for a denition of manipulation. 3.1.2. The line of action of this force is perpendicular to the articular surface of the affected joint The earliest biomechanical studies to investigate what is now termed manipulation (Roston and Wheeler Haines, 1947; Unsworth et al., 1971) examined the phenomenon of joint cracking in metacarpophalangeal (MCP) joints. These studies investigated the relationship between joint surface separation and the production of a crack sound (discussed in more detail later). Both studies used a similar design to induce the cracking sound in that the surfaces of MCP joints were separated using traction force, which was applied along the length of the nger, perpendicular to the articular surfaces. The results were equally simple: joint surface separation beyond a certain magnitude created an obvious cracking sound and an immediate increase in articular surface separation. For a short, unspecied period this cracking noise could not be repeated; an observation explained by reduced cohesion within synovial uid due to the presence of tiny bubbles (Unsworth et al., 1971; Mierau et al., 1988; Evans, 2002). Similar ndings were found in later al and Scott, 1986; Watson et al., studies of MCP joint cracking (Me 1989). Importantly, in every study in which the cracking sound in MCP joints has been examined, the force has always been applied along a line of action perpendicular to the articular surfaces of the affected joint. Moreover, the motion produced by this force was joint surface separation, without any obvious gliding motion. As synovial joint surfaces are designed to glide smoothly over one another, the motion produced during this type of MCP joint manipulation is hence distinguished from that produced during typical physiological motion. A complexity of this feature is that most synovial joints are curved rather than planar, and are not always congruent. Whereas

characteristic shown to be surplus or redundant in any part of the body. Previous attempts at a denition of manipulation have appeared in diverse sources of literature (representative examples are given in Table 2), and reveal several notable features. Firstly, when compared to the criteria in Table 1, it is clear that most of these previous denitions are actually descriptions. Furthermore, none of these can qualify as denitive as there is variation, and discordance, between them. Lastly, none is empirically-derived using the existing basic science literature on manipulation; a process that has the potential to identify characteristics that may distinguish manipulation from other physical treatments. One consistent attribute of previous denitions is that they relate to a physical intervention (or action) that one person (usually a practitioner) performs upon another (the recipient, who may be a healthy subject or patient). General (colloquial) denitions of the term manipulation focus entirely upon the action of the practitioner, without conveying the potential importance of the events that occur within the recipient. In comparison, many denitions in a therapeutic context describe a proposed mechanical effect (or response) within the recipient, which is caused by the action. This mechanical response may be associated with distinct physiological, neurological or psychological responses (Evans, 2002; Cramer

Table 2 Previous denitions and descriptions of manipulation and spinal manipulation. Denition/description (quotes) General (colloquial) To handle something, or move or work it with the hands, especially in a skilful way Therapeutic (general) To apply therapeutic treatment with the hands to (a part of the body) The therapeutic application of manual force Source Chambers 21st Century Dictionary, 2009 Chambers 21st Century Dictionary, 2009 American Association of Colleges of Osteopathic Medicine, 2006 Chartered Society of Physiotherapy, 2006 Gatterman and Hansen, 1994

High velocity, low amplitude passive movements that are applied directly to the joint or through leverage A manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit Therapeutic (spinal) Spinal manipulation is . the sudden application of a force, whether by manual or mechanical means, to any part of a persons body that affects a joint or segment of the vertebral column Spinal manipulation entails high velocity, low amplitude manual thrusts to spinal joints that extend slightly beyond their physiological range of motion

New South Wales Department of Health, 2001

Ernst, 2001

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the line of action of the applied force may be perpendicular to one point along the articular surface, this will not be the case with the entire articular surface. Hence, the applied force may be more accurately described as acting perpendicular to a plane that is tangential to a point of contact between the articular surfaces of the joint. Although the relationship between forces applied to spinal segments during manipulation procedures and the motion that ensues is often assumed to be self-evident, the existence of coupling patterns in spinal segments can preclude such certainty. Limited kinematic data exist for spinal segmental and joint motions during spinal manipulation procedures. However, the little data that are available do appear to validate this proposed feature in the spine (Evans, 2009). Bereznick (2005) measured substantial force applied perpendicular to the skin surface during side-posture lumbar manipulation. Due to the negligible friction between the skin and the underlying tissues (Bereznick et al., 2002), the line of action of the majority of this force can be assumed to have been parallel to the transverse plane of the recipient. Additionally, Cramer et al. (2002) conrmed that the same side-posture lumbar spine manipulation technique produces transverse rotation of lumbar spinal segments. Since transverse rotation in the lumbar spine is not obviously coupled with any other motion (Legaspi and Edmond, 2007), the applied force is again likely to act along the transverse plane of the recipient. In turn, the approximately planar articular surfaces of all lumbosacral posterior joints are perpendicular to the transverse plane; typical lumbar zygapophysial joints (L1L5) are aligned close to the sagittal plane, whereas those of the lumbosacral (L5S1) joints are more frontally orientated (Giles, 1997; van Schaik et al., 1997; Singer et al., 2004). Evidence for a similar relationship exists in the thoracic spine. l et al., 1995) have Several studies (Herzog et al., 1993a, 2001; Ga shown that manipulation forces are applied in a posterior-anterior direction, parallel with both sagittal and transverse planes, and therefore perpendicular to the frontal plane. In contrast, the articular surfaces of typical thoracic zygapophysial joints (T410) are known to be frontally orientated (Singer et al., 2004). Unfortunately, there are limited kinematic data available for cervical spine manipulation, but the small amount that does exist also provides support for this proposed feature (Evans, 2009). 3.1.3. The magnitude of this force increases to a peak over a nite period of time The available data demonstrate that the magnitude of the applied force varies considerably between individuals, but consistently increases from zero over a nite period of time until a peak force is reached, after which the magnitude decreases once again to zero, in a single, non-repeating cycle. The increase and decrease of the force is not necessarily linear, sometimes taking the form of several distinct phases of unequal duration that vary with the location of the manipulated joint (Roston and Wheeler Haines, 1947; Unsworth et al., 1971; Watson et al., 1989; Hessell et al., 1990; Kawchuk et al., 1992; Kawchuk and Herzog, 1993; Herzog et al., 1993a; Herzog, 2000). These observations suggest temporal limits for manipulation forces, in contrast to other manual therapeutic interventions (e.g. mobilisation), which may consist of periodical, repeating phases (Lee et al., 2000). However, it is difcult to justify that such forcetime constraints are necessary for manipulation. It is feasible that manipulation could still be achieved if the force-time characteristics varied from that typically observed. Furthermore, other interventions may be modied to share such characteristics. Hence, specifying the time frame over which force is applied is not currently proposed as a necessary criterion to dene manipulation.

3.2. Mechanical response (that which occurs within the recipient) 3.2.1. The applied force produces motion at a joint The force applied to the recipient induces motion between the articular surfaces of a joint. This is a fundamental feature of manipulation and other manual therapy interventions (Lee et al., 2000), and is frequently indicated in previous descriptions and denitions (e.g. Table 2). We consider this criterion to be necessary. While manipulation is often applied with the intent of producing an effect at a specic joint (or joints), research has demonstrated that some manipulation techniques are not sufciently accurate to always affect the chosen, target joint (Ross et al., 2004). It is therefore more precise to refer to the affected joint rather than the target joint. 3.2.2. This joint motion always includes articular surface separation The applied force induces motion between the articular surfaces of the affected joint, and when measured, articular surface separation (gapping) has always been observed (Roston and Wheeler Haines, 1947; Unsworth et al., 1971; Mierau et al., 1988; Watson et al., 1989; Watson and Mollan, 1990; Cramer et al., 2002). We propose that this is a necessary criterion for a denition of manipulation as few, if any, other manual therapeutic interventions appear to produce this type of joint motion. 3.2.3. The velocity of joint motion is variable One of manipulations most common pseudonyms is the high velocitylow amplitude thrust a composition of biomechanical terms frequently appearing in prior denitions (e.g. Table 2). Velocity is the rate of change of displacement with respect to time. High velocity joint motion may occur during everyday activities (e.g. throwing, running or kicking), as well as during passive manual or instrument-assisted procedures (e.g. manipulation and mobilisation). Hence, the velocity of joint motion alone cannot dene manipulation. Moreover, several studies have shown that manipulation may be achieved at relatively low velocity joint al and Scott, 1986; Watson et al., motions (Unsworth et al., 1971; Me 1989; Suter et al., 1994). Thus, given the current available data, velocity is not considered a necessary criterion. 3.2.4. The sum displacement of the articulating bones is usually zero Importance has been attached to the amplitude of joint motion achieved during physical interventions, and a grading system has been proposed (Maitland, 1966). However, the sum (resultant) displacement or deformation of tissue does not appear to be a necessary feature for the achievement of manipulation. Assuming that tissues have not undergone damage through being deformed beyond their elastic limit, are no longer under the action of any external force, and are under constant environmental temperature (Watson et al., 1989; Kernohan et al., 1990) and pressure (Semlak and Ferguson, 1970), all studies that have measured bone displacement before and after manipulation show no lasting change, once elastic tissue deformation has been allowed to recover l (Unsworth et al., 1971; Mierau et al., 1988; Watson et al., 1989; Ga et al., 1994, 1995, 1997; Tullberg et al., 1998; Cramer et al., 2002). As such, the nal resultant displacement of the articulating bones following a manipulation is usually zero. This raises some concern with use of the term adjustment, which conveys a notion of lasting tissue displacement. This feature was considered useful as it distinguishes manipulation from procedures to reduce a dislocation or realign fractured bone. However, it is conceivable that a manipulation delivered with excessive force may damage some of the joints restraining tissues, and result in lasting tissue displacement or deformation. Moreover,

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a manipulation that induces tissue damage is still manipulation, irrespective of an adverse outcome. Hence, the criterion for zero tissue displacement seems unnecessary for the denition of manipulation. 3.2.5. Cavitation occurs within the affected joint Associated with joint surface separation is the elicitation of a high frequency vibration that manifests as an audible click or crack sound (Roston and Wheeler Haines, 1947; Unsworth et al., 1971; Watson et al., 1989). These vibrations are readily measured using microphones or accelerometers, and have been investigated al and Scott, 1986; in various joints across several studies (Me l et al., 1995; Reggars Watson et al., 1989; Herzog et al., 1993b; Ga and Pollard, 1995; Reggars, 1996a,b, 1999; Beffa and Mathews, 2004; Bolton et al., 2007). The most likely and widely accepted explanation for this audible sound during joint manipulation is a process known as cavitation, occurring within the synovial uid of the affected joint (Evans and Breen, 2006). Cavitation is an engineering term used to describe the formation and activity of bubbles (or cavities) within uid, which are formed when tension is applied to the uid as a result of a local reduction in pressure (Unsworth et al., 1971; Trevena, 1987; Young, 1999). Evidence for this explanation of the sound has come in several forms. There is face validity for cavitation as the explanatory mechanism of joint cracking. The earliest scientic study of the phenomenon identied articular surface separation as a key component (Roston and Wheeler Haines, 1947). The characteristic triphasic forcedisplacement graphs obtained during increasing joint surface separation (Roston and Wheeler Haines, 1947; Unsworth et al., 1971; Watson et al., 1989), combined with the divergent return pathway, are strongly suggestive of a rapid and temporarily irreversible change in the cohesive properties of synovial uid, which was brought about by increased intra-articular volume and consequent decreased intra-articular pressure. In synovial joints, the reduction in intra-articular pressure is likely only achieved with a corresponding deformation of the joint capsule (Brodeur, 1995), although this suggestion remains speculative. Radiographs have consistently demonstrated a radiolucent region between the articular surfaces of the affected joint, immediately following the elicitation of the sound, whilst these surfaces remain separated (Fick, 1911; Dittmar, 1933; Nordheim, 1938; Fuiks and Grayson, 1950; Unsworth et al., 1971; Watson and Mollan, 1990). No study has measured how long this state may persist by continuously maintaining joint surface separation, although theoretically this could be indenitely (Roston and Wheeler Haines, 1947). Finally, several studies have shown that the sound cannot be elicited more than once within a relatively short period of time after the articular surfaces of the affected joint are allowed to return to their resting conguration (Roston and Wheeler Haines, 1947; Unsworth et al., 1971); a period that has been shown to extend as long as 90 min following lumbar spine manipulation (Bereznick et al., 2008). Furthermore, the location and quantity of these high frequency vibrations recorded during manipulation procedures in the spine is consistent with them originating from the synovial zygapophysial joints (Ross et al., 2004; Bereznick et al., 2008). One may ask whether cavitation is a necessary feature of manipulation? Physiological changes may take place during manipulation in the absence of cavitation (e.g. electromyographic signals). However, cavitation is associated with distinct osteokinematics (Unsworth et al., 1971; Watson et al., 1989; Watson and l et al., 1995; Cramer et al., 2002). In addition, Mollan, 1990; Ga clinicians frequently regard cavitation as an indicator of success in

the technical delivery of a manipulation (Evans and Breen, 2006). Conversely, some commentators consider cavitation to be an unnecessary outcome of manipulation because research has yet to demonstrate an association with clinical outcomes (Flynn et al., 2003, 2006). Nevertheless, for the purpose of dening manipulation, the clinical success, or otherwise, of the intervention is irrelevant. By corollary, the occurrence of surgery, acupuncture or any other physical intervention would not be dened by a successful or failed clinical outcome. Cavitation may also, on occasion, occur spontaneously during everyday movements, or during extreme joint motions that may damage a joint. Hence, the occurrence of cavitation in isolation cannot constitute a denition of manipulation. We propose that cavitation is a necessary feature of manipulation. However, we are aware that the inclusion of this criterion will be controversial for the reasons given above. It is also reasonable to argue that cavitation is not the intended outcome of other types of manual therapeutic interventions. For example, traction of peripheral joints has been shown to result in joint surface separation (Hsu et al., 2008). If such a procedure resulted in cavitation, then this would, by denition, be a manipulation. By contrast, traction of the lumbar spine does not result in zygapophysial joint surface separation (Humke et al., 1996); a likely consequence of the complex kinematics of spinal segments (Evans, 2009). Alternatively, if all other proposed criteria were present, yet cavitation was not achieved, this would not full all necessary criteria of a manipulation so should not be referred to as such. 4. Summary Of the features discussed above, those we propose to be necessary for the achievement of manipulation are summarised in Table 3. We have attempted to retain the minimum number of features. Collectively, these features should sufciently constitute the required components of a valid denition. Used in isolation, each of these features is insufcient to dene manipulation; their sufciency is dependent upon their collective occurrence. This is consistent with dening causal mechanisms as a set of factors that are jointly sufcient to induce an outcome event (Rothman, 1976); under the omission of just one factor, the outcome would be different. Fig. 1 demonstrates the relationship of the proposed necessary features of manipulation compared to other manual therapy interventions, illustrating their potential importance within a wider empirically-derived taxonomy of manual therapy. An important attribute of our proposed features is that they are explicitly divided into two categories: the action (that which the practitioner does to the recipient) and the mechanical response (that which occurs within the recipient). Interestingly,

Table 3 Proposed necessity of manipulation features. Necessary Action (that which the practitioner does to the recipient) A force is applied to the recipient The line of action of this force is perpendicular to the articular surface of the affected joint The magnitude of this force increases to a peak over a nite period of time Mechanical response (that which occurs within the recipient) The applied force creates motion at a joint This joint motion includes articular surface separation The velocity of joint motion is variable The sum displacement of the articulating bones is usually zero Cavitation occurs within the affected joint Yes Yes No

Yes Yes No No Yes

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Fig. 1. The relationship of the proposed necessary features of manipulation, compared with other manual therapy interventions.

whilst all of the action features are included at the discretion of the practitioner (and if any are excluded, the minimally sufcient criteria for manipulation would not be met), there is a causative chain in operation with the response features; once all of the action components have been achieved, the induction of some joint motion is necessary for the occurrence of joint surface separation, and in turn this is necessary for the occurrence of cavitation (Fig. 1). 5. Conclusion We have identied empirically-derived features of manipulation that we propose to be necessary for a valid denition, and have provided arguments for and against their inclusion in such a denition. In addition, we have specied that each feature must occur in order that the required dening criteria for manipulation are met and that it be clearly distinguished from other manual therapeutic interventions within a wider empirically-derived taxonomy of manual therapy. References
American Association of Colleges of Osteopathic Medicine. Glossary of osteopathic terminology. The Educational Council on Osteopathic Principles and the American Association of Colleges of Osteopathic Medicine. Available at: http:// www.osteopathic.org/pdf/sir_collegegloss.pdf; 2006. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther 2004;27(2):e2. Bereznick DE. Lumbar manipulation: quantication and modication of the external kinetics affecting the presence and site of cavitation (PhD thesis). Ontario: University of Waterloo; 2005.

Bereznick DE, Ross JK, McGill SM. The frictional properties at the thoracic skin fascia interface: implications in spine manipulation. Clin Biomech (Bristol Avon) 2002;17(4):297303. Bereznick DE, Pecora CG, Ross JK, McGill SM. The refractory period of the audible crack after lumbar manipulation: a preliminary study. J Manipulative Physiol Ther 2008;31:199203. Bolton PS, Budgell BS. Spinal manipulation and spinal mobilization inuence different axial sensory beds. Med Hypotheses 2006;66(2):25862. Bolton A, Moran RW, Standen C. An investigation into the side of joint cavitation associated with cervical spine manipulation. Int J Ost Med 2007;10(4): 8896. Brodeur R. The audible release associated with joint manipulation. J Manipulative Physiol Ther 1995;18(3):15564. Chartered Society of Physiotherapy. Clinical guidelines for the physiotherapy management of persistent low back pain. Part 2: manual therapy. London: Chartered Society of Physiotherapy; 2006. p. 32. Chambers 21st century dictionary. Available at. Glasgow: HarperCollins, http:// www.chambersharrap.co.uk/chambers/features/chref/chref.py/ main?queryretribution&title21st; 2009 [accessed January 2009]. Colloca CJ, Keller TS, Gunzburg R. Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy. J Manipulative Physiol Ther 2004;27(1):115. Colloca CJ, Keller TS, Harrison DE, Moore RJ, Gunzburg R, Harrison DD. Spinal manipulation force and duration affect vertebral movement and neuromuscular responses. Clin Biomech (Bristol Avon) 2006;21(3):25462. Coulter ID, Hurwitz EL, Adams AH, Meeker WC, Hansen DT, Mootz RD, et al. The appropriateness of spinal manipulation and mobilization of the cervical spine. Santa Monica: RAND. Available at: http://www.rand.org/pubs/monograph_ reports/2007/MR781.pdf; 1996. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine 2002;27(22): 245966. Cramer G, Budgell B, Henderson C, Khalsa P, Pickar J. Basic science research related to chiropractic spinal adjusting: the state of the art and recommendations revisited. J Manipulative Physiol Ther 2006;29(9):72661. r Ro ntgenologie des Kniegelenks. Verhandlaingen Deutschen OrthoDittmar O. Zu pedischen Gesellschaft (27 Congr., Mannheim, 1932); 1933. Ernst E. Life-threatening complications of spinal manipulation. Stroke 2001;32(3): 80910.

D.W. Evans, N. Lucas / Manual Therapy 15 (2010) 286291 Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007;100(7):3308. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. J Manipulative Physiol Ther 2002;25(4): 25162. Evans DW, Breen AC. A biomechanical model for mechanically efcient cavitation production during spinal manipulation: prethrust position and the neutral zone. J Manipulative Physiol Ther 2006;29(1):7282. Evans DW. Why do spinal manipulation techniques take the form they do? Towards a general model of spinal manipulation. Man Ther 2009;. doi:10.1016/ j.math.2009.03.006. Fick R. Zum Streit um den Gelenkdruck. Anat Hefte (Abt. 1) 1911;43:397. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil 2003;84(7):105760. Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. J Manipulative Physiol Ther 2006;29(1):405. Fuiks DM, Grayson CE. Vacuum pneumarthrography and the spontaneous occurrence of gas in the joint spaces. J Bone Jt Surg Am 1950;32A(4):9338. l J, Herzog W, Kawchuk G, Conway P, Zhang Y-T. Biomechanical studies of spinal Ga manipulative therapy (SMT): quantifying the movements of vertebral bodies during SMT. J Can Chiropractic Assoc 1994;38(1):1124. l JM, Herzog W, Kawchuk GN, Conway PJ, Zhang Y- T. Forces and relative vertebral Ga movements during SMT to unembalmed post-rigor human cadavers: peculiarities associated with joint cavitation. J Manipulative Physiol Ther 1995;18: 49. l J, Herzog W, Kawchuk G, Conway PJ, Zhang YT. Movements of vertebrae during Ga manipulative thrusts to unembalmed human cadavers. J Manipulative Physiol Ther 1997;20(1):3040. Gatterman M, Hansen D. The development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17(5):3029. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ. Rating specic chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2001;24(7):44956. Giles LGF. Zygapophysial (facet) joints. In: Giles LGF, Singer KP, editors. Clinical anatomy and management of low back pain. Oxford: Butterworth Heinemann; 1997. p. 7296 [chapter 5]. Harvey E, Burton AK, Moffett JK, Breen A, UK BEAM trial team. Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations. Man Ther 2003;8(1): 4651. Herzog W. The mechanical, neuromuscular, and physiologic effects produced by spinal manipulation. In: Herzog W, editor. Clinical biomechanics of spinal manipulation. New York: Churchill Livingstone; 2000. p. 191207 [chapter 5]. Herzog W, Conway PJ, Kawchuk GN, Zhang Y, Hasler EM. Forces exerted during spinal manipulative therapy. Spine 1993a;18(9):120612. Herzog W, Zhang YT, Conway PJ, Kawchuk GN. Cavitation sounds during spinal manipulative treatments. J Manipulative Physiol Ther 1993b;16(8):5236. Herzog W, Kats M, Symons B. The effective forces transmitted by high-speed, lowamplitude thoracic manipulation. Spine 2001;26(19):210510. Hessell BW, Herzog W, Conway PJ, McEwen MC. Experimental measurement of the force exerted during spinal manipulation using the Thompson technique. J Manipulative Physiol Ther 1990;13(8):44853. Hsu AT, Chiu JF, Chang JH. Biomechanical analysis of axial distraction mobilization of the glenohumeral joint a cadaver study. Man Ther 2009;14(4):3816. Humke T, Grob D, Grauer W, Sandler A, Dvorak J. Foraminal changes with distraction and compression of the L4/5 and L5/S1 segments. Eur Spine J 1996;5(3): 1836. Kawchuk GN, Herzog W, Hasler EM. Forces generated during spinal manipulative therapy of the cervical spine: a pilot study. J Manipulative Physiol Ther 1992;15(5):2758. Kawchuk GN, Herzog W. Biomechanical characterization (ngerprinting) of ve novel methods of cervical spine manipulation. J Manipulative Physiol Ther 1993;16(9):5737. Keller A, Hayden J, Bombardier C, van Tulder M. Effect sizes of non-surgical treatments of non-specic low-back pain. Eur Spine J 2007;16(11):177688. Keller TS, Colloca CJ, Beliveau JG. Force-deformation response of the lumbar spine: a sagittal plane model of posteroanterior manipulation and mobilization. Clin Biomech (Bristol Avon) 2002;17(3):18596. Kernohan WG, Beverland DE, McCoy GF, Hamilton A, Watson P, Mollan R. Vibration arthrometry. A preview. Acta Orthop Scand 1990;61(1):709. Kirstukas SJ, Backman JA. Physician-applied contact pressure and table force response during unilateral thoracic manipulation. J Manipulative Physiol Ther 1999;22(5):26979. l JM, Herzog W. Biomechanics of manual therapy. In: Dvir Z, editor. Lee M, Ga Clinical biomechanics. Philadelphia: Churchill Livingstone; 2000. p. 20938 [chapter 9].

291

Legaspi O, Edmond SL. Does the evidence support the existence of lumbar spine coupled motion? A critical review of the literature. J Orthop Sports Phys Ther 2007;37(4):16978. Maitland GD. Manipulationmobilisation. Physiotherapy 1966;52(11):3825. al GM, Scott RA. Analysis of the joint crack by simultaneous recording of sound Me and tension. J Manipulative Physiol Ther 1986;9(3):18995. Mierau D, Cassidy JD, Bowen V, Dupuis P, Noftall F. Manipulation and mobilization of the third metacarpophalangeal joint. Man Med 1988;3:13540. New South Wales Department of Health. Denition quoted in Chiropractors Bill and Osteopaths Bill. Available at: http://www.parliament.nsw.gov.au/prod/parlment/ HansArt.nsf/448b6decbe0283adca2571e1001663bb/ ca256d11000bd3aaca256a2a0027baee!OpenDocument; 2001. Nordheim Y. Eine neue Methode den Gelenkknorpel besonders die Kniege ntgenologisch darzustellen. Fortschr Ro ntgenstr 1938;57: lenkmenisken ro 479. a E, Eisenberg D, Fincher J, Hufford DJ, et al. (Panel OConnor BB, Calabrese C, Carden on denition and description, CAM research methodology conference, April 1995). Dening and describing complementary and alternative medicine. Altern Therap 1997;3(2):4957. Reggars JW. The manipulative crack: frequency analysis. Aust Chiro Osteopath 1996a;5(2):3944. Reggars JW. Recording techniques and analysis of the articular crack: a critical review of the literature. Aust Chiro Osteopath 1996b;5(3):8692. Reggars JW. Multiple channel recording of the articular crack associated with manipulation of the metacarpophalangeal joint: an observational study. Aust Chiro Osteopath 1999;8(1):1620. Reggars JW, Pollard HP. Analysis of zygapophyseal joint cracking during chiropractic manipulation. J Manipulative Physiol Ther 1995;18(2):6571. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specic? Spine 2004;29(13):14527. Roston JB, Wheeler Haines R. Cracking in the metacarpo-phalangeal joint. J Anat 1947;81(Pt 2):16573. Rothman KJ. Causes. Am J Epidemiol 1976;104:58792. Semlak K, Ferguson AB. Joint stability maintained by atmospheric pressure. An experimental study. Clin Orthop Relat Res 1970;68:294300. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, et al. The appropriate use of spinal manipulation for back pain: indications and ratings by a multi-disciplinary expert panel. Santa Monica: RAND. Available at: http:// www.rand.org/pubs/reports/2007/R4025.2.pdf; 1991. Singer KP, Boyle JJW, Fazey P. Comparative anatomy of the zygapophysial joints. In: Boyling JD, Jull G, editors. Grieves modern manual therapy: the vertebral column. 3rd ed. Edinburgh: Churchill Livingstone; 2004. p. 1729 [chapter 3]. Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106(12):15968. Song XJ, Gan Q, Cao JL, Wang ZB, Rupert RL. Spinal manipulation reduces pain and hyperalgesia after lumbar intervertebral foramen inammation in the rat. J Manipulative Physiol Ther 2006;29(1):513. Suter E, Herzog W, Conway PJ, Zhang YT. Reex response associated with manipulative treatment of the thoracic spine. J Neuromusculoskelet Syst 1994;2: 12430. Trevena DH. Cavitation and tension in liquids. Bristol: Adam Hilger; 1987. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine 1998;23(10):11248. Unsworth A, Dowson D, Wright V. Cracking joints. A bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis 1971;30(4): 34858. te P, Boyle E, et al. van der Velde G, Hogg-Johnson S, Bayoumi AM, Cassidy JD, Co Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis. Spine 2008;33(4 Suppl.):S18491. van Schaik JP, van Pinxteren B, Verbiest H, Crowe A, Zuiderveld KJ. The facet orientation circle. A new parameter for facet joint angulation in the lower lumbar spine. Spine 1997;22(5):5316. van Zoest GGJM, Gosselin G. Three-dimensionality of direct contact forces in chiropractic spinal manipulative therapy. J Manipulative Physiol Ther 2003;26: 54956. Watson P, Kernohan WG, Mollan RA. A study of the cracking sounds from the metacarpophalangeal joint. Proc Inst Mech Eng [H] 1989;203(2):10918. Watson P, Mollan RA. Cineradiography of a cracking joint. Br J Radiol 1990;63(746):1457. Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C. Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials. Complement Ther Med 2007;15(4):27183. Young FR. Cavitation. London: Imperial College Press; 1999.